Overthinking It

Dylan Bundy, Elbow Injuries, and the Evidence That PRP Works

When the news broke yesterday that Orioles prospect Dylan Bundy would have to have Tommy John surgery, most of you probably wondered why he hadn’t had it sooner.

It’s been almost three months since we became aware of an issue with Bundy’s elbow. The first reported red flag, “mild tightness,” was followed by an MRI that showed no structural damage, a few weeks of rest, a visit to Dr. James Andrews—who prescribed more rest and a platelet-rich plasma (PRP) injection—and several more weeks out of action. Bundy recently resumed a throwing program, but he suffered a setback that sent him back to Dr. Andrews and, ultimately, the operating room.

All of this sounds familiar, since we’ve seen this pre-surgery sequence before. And it’s extra frustrating for fans when a promising player spends half a season circling the drain; as disappointing as it is to lose someone like Bundy for a year or more, it’s even more galling to think that the timetable for return was pushed back by a doomed attempt to escape the inevitable. Orioles blog Camden Chat summed up the feelings of many Baltimore fans on Tuesday, saying:

If it ends up that Bundy does need the surgery, that will be a bitter pill to swallow, given that he has not been right since spring training. If he'd needed the surgery all along but went under the knife in March, he could be ready to go for next season.

Instead, Bundy will be sidelined until at least mid-2014, even assuming that everything goes smoothly. (The prognosis for Tommy John patients has improved, but as Ryan Madson has found out the hard way, a complete recovery isn’t assured.) Even aside from the risk, the O’s had every reason to exhaust the non-surgical options before sending Bundy’s UCL to the scrap heap: The rehab process is painful, time-consuming, and stressful, the Orioles need pitching help now, and Bundy isn’t accruing service time while he’s on the DL, since he was optioned to the minors before he got hurt. But to believe that Baltimore’s conservative approach was a smart one, you need to see some sign that PRP can help heal an injured UCL. Otherwise, you might well ask why the Orioles would waste time that Bundy could have used to start working his way back.

Over at Sports Illustrated’s “Strike Zone” blog, Cliff Corcoran listed several cases in which PRP failed to prevent surgery and noted how hard it was to find examples where it worked, concluding:

But sometimes our instincts are off. As a counterpoint to our collective fatalistic attitude about elbow injuries, allow me to present a paper with the attention-grabbing title, “Treatment of Partial Ulnar Collateral Ligament Tears in the Elbow with Platelet-Rich Plasma.” Authored by five doctors from the Kerlan-Jobe Orthopaedic Clinic in Los Angeles, including the late Lewis Yocum, the paper was presented at a meeting of The American Orthopaedic Society for Sports Medicine in February and published in The American Journal of Sports Medicine in May. You’ll need a subscription to read the full article, but the abstract is available online.

In short, there is evidence that PRP works on the injury Bundy had, and this paper provides it. The “background” section of the abstract acknowledges that prior to the paper’s appearance, there were “no published reports of clinical outcomes of partial ulnar collateral ligament (UCL) tears of the elbow treated with PRP.” Now there’s at least one, and it offers pretty strong support for the PRP procedure.

The paper charts the progress of 34 athletes with a partial-thickness UCL tear—like Bundy’s—confirmed on MRI. All 34—27 of them baseball players, 16 of whom pitched—“had failed at least two months of nonoperative treatment and an attempt to return to play.” They were subjected to a battery of tests, questionnaires, and measurements designed to provide a pre-PRP baseline that their progress could be compared to after the procedure. And then they received their injections.

The results were encouraging. After an average follow-up time of 70 weeks, 30 of the 34—88 percent—“had returned to the same level of play without any complaints.” On average, it took them 12 weeks to get back into games, and the same tests they’d taken prior to PRP confirmed their improvement. Only one of the 34 had ligament reconstruction surgery in the period spanned by the study. It’s important to note that there was no control group, so we don’t know how many of the 34 might have made it back with rest and rehab but without PRP. But we do know that with PRP, almost all of them avoided going under the knife. Based on those results, the paper concludes that “PRP is an effective option to successfully treat partial UCL tears of the elbow in athletes.”

Team doctors and trainers aren’t stupid, and they probably wouldn’t continue to waste time (and many millions of dollars) and stake their reputations on an experimental procedure with no history of success. The instances when the rest-and-rehab approach didn’t pan out tend to stick in our minds more easily than the successes, and since players’ PRP use isn’t always public knowledge, we don’t necessarily know when it works out. But what data we do have suggests that PRP is often worth the wait.

The next time I hear that someone is experiencing elbow soreness, I’ll probably still catch myself assuming a season-ending injury. But there is some reason to hold out hope. And if rest, rehab, and PRP don’t pay off, we can’t conclude that they weren’t worth trying.

Great article! It inspired a couple of questions:
*Are there any examples of MLB players who got PRP and successfully avoided TJS? I can't think of one, though I don't follow injuries closely. It just struck me that the article you cite to (which I haven't read) refers to "athletes", implying some non-baseball players, and I'm guessing they aren't all top-level professional performers in their fields. Is it possible that there's something specific about pitching a baseball, or doing so with the intensity that MLBers do, that makes PRP less effective with them?

*Could/should(/do?) teams give their pitchers regular PRP injections throughout the year, either to try to prevent injuries or to help recover from the "ordinary" wear-and-tear they incur? And would that reduce recovery time and allow more frequent starts/appearances?

There were a few non-baseball players but there were 27 baseball players included in the study, 16 of which pitched.

It's important to note that players who had full-thickness tears were not included in the study, so only those who had mild to moderate injuries were included.

Overhead throwers obviously have greater loads across their elbows but the severity of the tears is of greater importance. Larger tears or tears with a significant amount of scarring already present, don't appear to have a good outcome based on the limited research in this population. Further studies may show a more optimal concentration of PRP or the subsequent rehab in this group, but right now the evidence just isn't there.

Also in terms of it appearing to be less effective in MLB players, often they will continue pitching until the injury becomes more severe or has a lot of scarring in it and the pitcher just can be effective anymore. By this time, the healing potential is less optimal than if it was done earlier in the process. One potential factor could be that MLB pitchers tend to throw harder than those at other levels and velocity is a key factor in getting a UCL injury in the first place.

In terms of "preventative" PRP injections for lack of a better word, they certainly could not do it during the season. A few months is needed after the injection for the healing factors to take hold before significant stress could be placed upon it. Also, if there is no injury present, PRP won't help prevent an injury from happening. It's more of a tool to use afterwards to help the body heal properly.

In terms of using it in the off-season with the "wear & tear" type injuries, there may be something to that in the future but there are still too many unknowns to use it in those not showing any symptoms. A lot more research is being done and it wouldn't surprise me that PRP will start being used in some of these cases.

What type of athletes are these? How many are pitchers? I would imagine, for example, that the strain on an athlete's UCL is different for a pitcher than for a first baseman or even a wide receiver or golfer (I mention golf, because Tiger Woods has a similar injury right now). While a general athlete may have high recovery rates, I could see that being much lower for pitchers.

Good stuff, Ben and Corey. So at some level of granularity, no two tears are the same, correct? A partial tear implies less than 50 percent. Do physicians think in terms of, say, 10-20 percent tear vs. 60-70 percent torn? If so, it might also suggest that there is a threshhold above which PRP therapy would be viewed clinically as pointless or even counter-productive (in terms of putting off the inevitable).

Following on that, is there any reason to think that the odds of recovery from TJS are in any way a function of the severity of the tear? It seems plausible that a 10% tear, surgically repaired, would be more likely to heal fully than a 90% tear. Or is that not so? The reason I wonder is that since teams would have no incentive to report the severity of the tear by percentage, PRP could give us an indication of that. Hence even if PRP failed and surgery happened, the choice to try PRP could be viewed as a measure of the severity of the tear and therefore a possible predictor of recovery, assuming of course that there is a positive relationship between lesser tears and greater odds of recovery.

Have I wandered all the way off the pier into the ocean? Why are my shoes wet?

I think the surgery involves replacing the ligament with a substitute from elsewhere in the body, so the degree of the tear is not important. From previous stuff about this, I think anything more than about a 25% tear is thought to be unlikely to heal without surgery.

Is it easy to get a relatively accurate diagnosis as to what percentage of tear there is? Seems to me this might be a problem if Bundy had a clean MRI, but had enough of a tear that it couldn't heal with rest and PRP.

Yes and no. On the MRIs you can get a rough idea but you won't be able to get it down to single percentage points, i.e. 56 vs 57%.

Using diagnostic musculoskeletal ultrasound, they can get a more accurate picture because they can physically measure how much the distance the elbow is opening up/looseness as a stress is being placed upon it. This is ultimately a much better idea of how problematic the elbow can be. In the study it showed that the elbow became "tighter" by about 7mm on average, which is a pretty significant finding and not just "feeling" better according to the pitcher.

So I think that we're slowly getting a more precise number but at the same time there will still be variability between people.

The number percentage while important in some ways, but it is not as important as the actual stability of the elbow. An elbow with a lower percentage tear could be more unstable (that is looseness that causes symptoms) than a higher percentage tear. Usually though as you would expect the higher the percentage in the partial tear realm, the more unstable it is.

Right now there is no hard or fast rule as to what percentage a partial tear should skip the conservative treatment and go straight to surgery. If there is a complete tear than it is pretty apparent that conservative therapy won't work, but 30%, 50%, 70%, those are the questions that are trying to be answered with the research that is going on now.

TJS involving reconstructing the ligament, that is building a new one. There are several variations out there based on physician preference and experience, which augments the new ligament with the present ligament but the core of the surgery is to build a new one. Therefore, the odds of recovering from a 10% or 90% tear wouldn't really change from a pure ligament point of view. However, with larger tears, the instability can lead to other injuries that may change the odds, such as tearing of the overlying tendon, bone spurs and chips can occur, etc.

Right now it's pretty safe to assume that if PRP is being used the tear is on the mild to moderate side. Each physician and organization is different though and of course the player has a role in this too. If the player wants to avoid surgery with a 90% tear and have PRP, then ultimately it's his choice and may not be an indictment on PRP if it fails.

I feel like we haven't fully acknowledged the risk that accompanies being sliced open with a knife. I think if there's evidence that non-surgical treatments can be effective, it's almost irresponsible to not explore that.

No you are right, without a control group for a randomized controlled trial, specifics are hard to be drawn. That is why not every physician is doing PRP on cases of UCL injury.

It may also prove to be very difficult to get that random controlled trial. Imagine trying to explain after the fact that the injections were actually placebo and now the pitcher wasted 6 months or more for the advancement of science, but not for him.

It is an important first step though and eventually the level of evidence in this matter will improve, but I doubt we will ever be able to get randomized controlled trials involving placebo injections.

I wonder if they would be able to compare the results here to data from past UCL injuries that did not involve PRP. Obviously you'd lose the baseline measures that were taken in this study to aid in comparison, but it'd be better than nothing.

Why is it that everybody forgets that athletes actually have a say in whether or not their bodies will be cut on? Everybody is blaming the Orioles for the delay, and lost among the accusations is the fact that Bundy himself may very well have made the decision to explore all non-surgical options first. Surgery is not without risks. Athletes are people too, and most people try to avoid surgery when viable, potentially successful other options exist.